Provider Demographics
NPI:1538675194
Name:WALLACE FAMILY CHIROPRACTIC PA
Entity Type:Organization
Organization Name:WALLACE FAMILY CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-469-9777
Mailing Address - Street 1:502 N SPRING GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3193
Mailing Address - Country:US
Mailing Address - Phone:386-469-9777
Mailing Address - Fax:386-469-9070
Practice Address - Street 1:502 N SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3193
Practice Address - Country:US
Practice Address - Phone:386-469-9777
Practice Address - Fax:386-469-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty